Financial Hardship Policy new

2018 Financial Hardship Policy

Purpose:

Integritas has established this policy to maintain consistency in assisting indigent patients who request a reduction or waiver of certain medical expenses and/or copayment amounts.

This policy outlines Integritas' policies and procedures in relationship to the application and approval process for patients who otherwise are unable to pay or afford the costs of medical expenses. Integritas will take into account the overall financial circumstances of the applicant and apply this policy consistently.

If approved, Integritas may elect to reduce or waive certain amounts which are due from uninsured or underinsured patients who can successfully demonstrate that paying medical expenses would cause significant financial hardship.

Financial Hardship Criteria:

Integritas will take into account a range of factors when deciding whether the full payment of the medical expenses will cause the applicant or its financial guarantor a financial hardship. In making the decision whether to reduce on a sliding scale or waive certain fees, Integritas will review the household income, living expenses, and debts. Written verification, in some instances, may be required to substantiate and verify information contained in the financial hardship application.

Integritas reviews all applications in combination with the current year's federal poverty guidelines to assist in determining qualifications for a financial hardship reduction or waiver. (Attachment A)

In applying these guidelines, Integritas will also consider and take into account any other income and expenses including money earned in the entire household. Income and employment status verification may be required, including tax returns, check stubs, etc.

Integritas will take into consideration the following factors:

1. Whether payment of the medical expenses will affect the applicant's ability to pay for the following living expenses:

? food and clothes; ? rent or mortgage payments; ? any other basic needs; or ? any special needs (for a serious illness or disability).

2. Whether the applicant owns any assets, such as a car or house. Assets also include the following:

? investments; ? money in the bank; ? cash on hand for short-term expenses; ? money designated for special needs; ? refunds of taxes; ? money owed to applicant by any third party.

3. Existence and amount of any outstanding debts.

4. Patient received services at one of Integritas' designated facilities by one of its providers or affiliate providers.

Application Process for Financial Hardship

An application for a financial hardship for medical expenses and fees must be made in accordance with Integritas' policy entitled "Financial Hardship Policy".

Applicants may request and complete a Financial Hardship Application Form. The form can be obtained by visiting the Integritas main office at 2250 N. Illinois Ave., Carbondale, IL, or online at for-patients. Forms can also be requested from the Integritas Business Operations office through submission of a written request via email at info@, fax at (618) 861-5302, or U.S. Mail at 2250 N. Illinois Ave, Carbondale, IL 62901. Applicants are required to return the completed forms and submit all required documentation to Integritas within 180 days of the date of service.

Required Information:

Integritas requires independent information to support claims of financial hardship including verification of expenses and income. The information submitted will be treated confidentially and will only be reviewed by Integritas administrative staff involved in processing and reviewing information for reduction or waiver of medical expenses.

Time Frame:

After an application and verification information are received, Integritas will consider the overall financial situation of the applicant and then render a decision. All decisions will be made within 10 working days from the time that Integritas receives and reviews all required information. All determinations are pursuant to the hardship guidelines and are discretionary and in the sole determination of Integritas.

Applicants will receive a notification letter outlining whether the application has been approved or denied. If an applicant's request for reduction or waiver of the charges is denied, Integritas will provide the applicant with a written notice of its determination. If the applicant's financial situation significantly changes, the patient or their designee may reapply.

Integritas administrative staff will maintain all documentation related to the financial hardship waiver process as confidential. This documentation will include all supporting documentation including the waiver request and all documents provided in support of the request.

Verification of ongoing qualification for financial hardship may be conducted at any time at Integritas' discretion or at the applicant's request.

PLEASE COMPLETE THE ATTACHED APPLICATION AND FINANCIAL STATEMENT. YOUR REQUEST CANNOT BE PROCESSED UNLESS THE APPLICATION AND FINANCIAL STATEMENT IS FULLY COMPLETED AND SIGNED!

Financial Hardship - Attachment A

2018 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA WITH DISCOUNT SCALE

Family Size

1 2 3 4 5 6 7 8 9 10

100% of FPL*

$12,140 $16,460 $20,780 $25,100 $29,420 $33,740 $38,060 $42,380 $46,700 $51,020

Gross Yearly Family Income (GYFI)

125% of

150% of

175% of

200% of

FPL*

FPL*

FPL*

FPL*

$15,175 $18,210 $21,245 $24,280

$20,575 $24,690 $28,805 $32,920

$25,975 $31,170 $36,365 $41,560

$31,375 $37,650 $43,925 $50,200

$36,775 $44,130 $51,485 $58,840

$42,175 $50,610 $59,045 $67,480

$47,575 $57,090 $66,605 $76,120

$52,975 $63,570 $74,165 $84,760

$58,375 $70,050 $81,725 $93,400

$63,775 $76,530 $89,285 $102,040

> 200% of FPL*

>$24,280 >$32,920 >$41,560 >$50,200 >$58,840 >$67,480 >$76,120 >$84,760 >$93,400 >$102,040

More than 10

Discount if ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download